Ted Simons: How does today's Supreme Court decision upholding the affordable care act affect the health concerns of Arizonans currently with or without health insurance? Here to share their views are Dr. Leonard Kirschner who served as director of Arizona's Medicaid program, known as AHCCCS, from 1987 to 1993.
He currently is the state president of AARP Arizona. Also joining us is Dr. Daniel Lieberman, a Phoenix neurosurgeon. Good to have you both here. Thanks for joining us. Your thoughts on today's decision?

Dr. Leonard Kirschner: I think it was a victory for America. And I think we're going to see more people get health care coverage than have had in the past. 50 million uninsured, 50 million underinsured, in Arizona 1.5 million uninsured. I think it's a step in the right direction. Perfect, no, definitely step in the right direction.

Ted Simons: Your thoughts?

Daniel Lieberman: Sad day for patients, Ted. The law as it is on the books right now is underfunded, it's not thought through, it's likely to change health care delivery in a way that's going to be very, very challenging for those of us who practice medicine for many years to come.

Ted Simons: Is there going to be a challenge here, because there's a lot unknown, but I know from the other side, there's a great concern on the number of doctors, the quality of care, the whole nine yards.

Dr. Leonard Kirschner: Well, we have this whole insurance accessibility, affordability, accountability this, law has dealt with the accessibility side. We clearly have to deal also with the cost side. And we need to deal with the quality of care. We still know that the most dangerous place to go in health care is to a hospital. We need to fix that. The current American health care system is chaotic, costly, inefficient, inequitable and superb, a paradox. We could do a lot better.

Ted Simons: We can do a lot better, we haven't done a lot better. Is this something that may not be perfect, but had to be done?

Daniel Lieberman: Ted, I think we solved the wrong problem. We expanded health care, I agree with the doctor, we made it a lot more available to hopefully 30 million more Americans, but what we expanded isn't working very well. No business would do what the government just did. Have you something that's inefficient, sometimes dangerous on the hospital side, often ineffective, and we just made the same thing available to a lot more people. When you really look at what makes health care inaccessible, it's the high cost. The Congress really tried to solve the wrong problem with this law, and by solving the wrong problem, we're going to get the wrong solution.

Ted Simons: Was this a solution in search of a problem?

Dr. Leonard Kirschner: No. The problems are clearly across the board. The three issues that we need -- three legs of the stool -- the cost, quality, accessibility to care. All three have to be dealt with. In Massachusetts, governor Romney dealt with the accessibility part. Massachusetts is now dealing with the cost side. You can't do it all at the same time. This was an effort clearly as you know as we go into legislation, I worked for three governors, nine chiefs of staff, as you go into legislation you never get it perfect. But what you get sometimes is the good.

Ted Simons: What is the major concern for doctors? Our -- this is your world here. What is your biggest concern?

Daniel Lieberman: I'm really worried that the relationship between the doctor and the patient is going to be adversely affected by this. As practicing physicians, we spent the last 20 years trying to deal with health care companies, health insurance, trying to help our patients get their needs met with the insurance company between us and the patient.

Dr. Leonard Kirschner The government –

Ted Simons: Hold on.

Daniel Lieberman: The government just sat down at the table. At the end of the day, if my patient is insured by a company and we can't get the right result with that company, they can change insurance companies. You can't change governments. We now have the government, the 800-pound gorilla, in the exam room participating not even on the state level, but on the federal level, in the most intimate of Americans' issues.

Dr. Leonard Kirschner: But this law actually puts constraints on those insurance companies. And I totally agree with you, there is -- I ran a fairly large insurance company called AHCCCS. There are constraints that are put on those insurance companies, particularly the for-profit insurance. The amount of money they can make, took medical underwriting, adverse selection and saying you can't come in our program. Today what we've got are about 3.5 million kids covered by the parents' care, we're closing the doughnut hole procedures, we've added preventive care. So there's a lot of really good
things in this law. Perfect, absolutely not. Needs to be worked on? Absolutely. But a step in the right direction.

Daniel Lieberman: I think each one of those represents really great ideas. But if you look at how they're being implemented under this law, the results have not been good. For example, closing the doughnut hole by maybe can medications more affordability for seniors, great idea; however, the government did it by making price controls on medications, we're now seeing shortages of specific drugs. Drugs that we've had for decades in medicine, we can't get access to. Because when the federal government controls the price of individual items, you get shortages. The preventive care services, this law creates a panel which determines which preventive care services are appropriate. Their first two decisions have been whoppers. You could find in this building a couple of women whose lives were saved by early mammograms.
Their first decision was that mammograms are unnecessary until age 50. It's just not true.

Dr. Leonard Kirschner: But that -- I've had – that doesn't go into effect until five years. You're talking about things that have been in place under previous administrations, on dealing with -- these are organizations that are around for a long time, that have made decisions on mammograms, PSA and other things. It's not part of the act.

Daniel Lieberman: It's the identical structure. The way the affordability care act, it does almost nothing for cost, which again I think is really the primary problem, the way it addresses cost is through a panel of 14 presidentially and congressionally appointed individuals who simply in their already active, they do not have the expertise which is required
to make these kinds of decisions. In addition, how can Washington, DC make protocols for practicing physicians that are valid for every individual in America? It's simply not possible.

Dr. Leonard Kirschner: I think that what we're seeing here is a step in the right direction. Evidence-based medicine moving in that direction. This panel doesn't exist until 2018. So what you're saying that they've done isn't so. They haven't even been appointed.

Ted Simons: Let me ask you a question. Another concern is you're going to have 30 million, something along these lines, folks that will now be getting insurance one way -- most of them. Some of them will still opt not
to pay, they'll pay the fine, or they'll decide they'll be -- 30 million or so on the rolls, getting health care. Do we have enough doctors?

Dr. Leonard Kirschner: No. And that's clearly one of the issues, because what we've done for so long in health care, we've paid for the wrong thing. So we end up with too many specialist and not enough primary care doctors. And clearly what we need was primary care doctors, nurse practitioners, physician assistance.

Ted Simons: What are the ramifications?

Dr. Leonard Kirschner: I think we're going to be muddling through for a while, but clearly that -- theincentives now, when we pay the primary care folks more, the incentive is to develop that primary care cadre.

Daniel Lieberman: If we tried to radically increase the number of physician we have in our market today, we're seven years out from seeing even one of those doctors see a single patient. What's at stake here is too important to muddle through. People will not lead the same lives. They will not is have the same care as these 30 million people who are presently uninsured are abruptly and shockingly brought into a system that is totally not ready to care for them. This is not the right way to do it.

Dr. Leonard Kirschner: But those people do get ill, injured and pregnant, those uninsured. And they do come in the system. They come in the worst way, they come to the E.D. That's a terrible place to provide care. I was sharing with you that 20 years ago I was in the White House proposing a plan for America in the Clinton years, receipting the Medicaid programs and AHCCCS. And so we could have said the same thing that, oh, seven years to produce another doctor, but reality is, 19 years a later woe would have had a lot of cadres.

Ted Simons: The president this morning mentioned people will have more affordability – no discrimination against preexisting conditions, can't be dropped if you're sick, premiums can't be increased without reason, women can't be charged more due to gender. Patients can't be billed into bankruptcy. Preventive care is now required. Those under 26 stay on the parents' plan, seniors get a discount. That's a lot of things that he said are now better because of this law. Do the better things he mentioned outweigh some of the concerns that bother you?

Daniel Lieberman: Those are wonderful things. Quite Frankly, we cannot afford them. We are expanding a system that already costs too much money in a way that we don't have the money to pay for these things. Look at the deficit we're dealing with right now. That's going to pale in comparison. A lot of the funding for this act was based on financial savings through the long-term insurance portion. That's already been thrown out. There's 18 new taxes in Obamacare, the first to be -- they're attempt to be throw out now is the 3% excise tax on medical devices. This is not affordable. This is a great idea, we don't have this kind of money.

Dr. Leonard Kirschner: We're the wealthiest nation in the world. There's no question we can do a health care system that is the equal of the other industrialized nations in the world. When you look at those nations, those systems, you look at ours, we failed dramatically. This is a step trying to move towards a more holistic program, a system that actually takes care of the people of America.

Ted Simons: But can you afford, especially when you've got -- folks who may not be able to afford the premiums no matter what the health care exchanges
looks like, or those who again decide they're not going to do this, maybe they'll pay a fine, but can you afford the subs education -- subsidize Asian of the folks who can't afford the premiums?

Dr. Leonard Kirschner: Absolutely. There's more enough money in the
health care system. 18% of GDP is so inefficient. This is a step to make it more efficient. I think there's more than enough financing in our health care system throughout this country to actually cover all Americans and do it in a way that is effective.

Ted Simons: Can we meet a challenge? If you -- you mentioned a lot of
challenges, can we meet those challenges?

Daniel Lieberman: Not with this act. We need to start over with reforms which are widely accepted. We need to deal with the cost side first. Once we solve the cost problem, we won't have an access problem to health care in the United States. And expanding it first really is going to throat baby out with the bath water.

Ted Simons: Do you think what happened today and the continued reforms here from the affordability care act, do you think that is worse than leaving the system in as it was?

Daniel Lieberman: Very much so. I'm sad for my patients. I'm worry today for my children. I don't know who's going to pay for all of this. I don't think my patients are going to have access to the quality care that they receive today in the United States. And this law is the reason.

Dr. Leonard Kirschner: I totally disagree. This law is a step in the right direction. There will have to be more changes, but your patients will have more access to you, there will be more with coverage, and it's going to be a positive step. Clearly the positive aspects of the president articulated today far outweigh the negatives. Is it perfect? No, it's going to be fixed, yes, it is going to be battled out in the election as we're going up to the conventions in November in the election, absolutely. But this is a step in the right direction.

Daniel Lieberman: I hope you're right.

Ted Simons: All right. Real quickly, bottom line, if you were insured right now, what
changes?

Dr. Leonard Kirschner: For me, because I'm old, I'm on Medicare, very little changes.If I had prescription drugs I would be doing better. If I had other issues I might be doing better.

Ted Simons: What changes for those on insurance right now?

Daniel Lieberman: Beginning in 2014 your access to physicians will be very, very much more difficult. As this mass number of people come in on the same terms with no relationship with physicians, they're going to absorb the resources of the system. Good luck to you.